Provider Demographics
NPI:1689411704
Name:WILLIAMS, REVONDA BONITA
Entity type:Individual
Prefix:MRS
First Name:REVONDA
Middle Name:BONITA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3768
Mailing Address - Country:US
Mailing Address - Phone:510-932-4764
Mailing Address - Fax:
Practice Address - Street 1:2425 BISSO LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4897
Practice Address - Country:US
Practice Address - Phone:925-521-5620
Practice Address - Fax:925-521-5642
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-ILRHOZ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist